Medical Mystery Monday #51: the case of the stretch marks

I survived Hurricane Irene unscathed – did you? Luckily I never lost power at my apartment so I was able to write a mystery for you all. Good luck cracking the case.

A 29 year old woman goes to her doctor because she has giant stretch marks on her abdomen. She has gained fifty pounds since her visit last year, even though she has not changed her diet or exercise regimen. She has also developed acne and some facial hair she did not have before. In addition, the patient only gets her menstrual cycle every other month, whereas before it had been regular. The patient is very upset about these changes, and admits she has been feeling depressed lately. She has no prior medical history and takes no medications.`

On physical exam, the patient has high blood pressure. When doing an eye exam, the doctor noticed she has lost her outer peripheral vision on both sides. She indeed has large stretch marks on her abdomen (shown below). He notices several bruises on the patient’s legs, and she explains that every time she bumps into something she bruises. When testing her strength, the muscle groups around her shoulders and hips are weak. The doctor also notices a lump on the back of her neck (shown below).

What is the most likely diagnosis?

References: uptodate.com, emedicine.medscape.com.

Notice the lump on the back of her neck, facial hair, and acne. From uptodate.com.

This patient has Cushing’s syndrome. How coincidental, because I was just on line last night researching this for myself. I was tested for this 16 years ago as part of an infertility workup and was told that I didn’t have hit, yet I continue to have every symptom. Perhaps I should be more insistent with my PCP to pursue this further.

Strike my first answer. This woman has Signs and symptoms of a functioning pituitary tumor. A functioning pituitary tumor that is making extra hormones. Her tumor is making too much ACTH, resulting in some loss of vision, weight gain in the face, neck, and trunk of the body, a lump of fat on the back of the neck, stretch marks on the abdomen,easy bruising,growth of fine hair on the face, upper back,anxiety, irritability, and depression.